Recurring concern

Insufficient care home management capacity and oversight

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First reported 4 Dec 2013•Latest report 9 Apr 2025

Definition

What this concern includes

Includes deficiencies in care-home management capacity or availability, including too few managers, absence of an on-site manager when required, and comparable failures that leave the care home without effective operational oversight.

Not included

  • Excludes frontline care staffing shortages where the concern is patient or resident care capacity rather than management capacity.
  • Excludes staff knowledge, training or competence deficiencies that are not specifically part of care-home management oversight.
  • Excludes failures of registration or qualification alone unless they directly contribute to inadequate management capacity or oversight.
  • Excludes generic organisational governance deficiencies not specifically concerning operational management of a care home.
Reports
11

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
22

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission4
Department of Health and Social Care2
Care First Class (UK) Limited1
Care First Homes1
Coed Duon1
Copperfields1
Corbett House Nursing Home1
Downham Grange1
Exemplar Health Care Services Limited1
Hc-One Limited1
HF Trust Limited1
Kingsley Care Homes Limited1
MyMil Limited1
Recipient name withheld1
Scraptoft Court Care Home1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Leicester City and South Leicestershire

    AI-generated summary

    Marjorie Evelyne Keogh · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marjorie Evelyne Keogh, a resident of Scraptoft Court Residential Care Home, fell through a first-floor landing balustrade while transferring to breakfast on 6 March 2010 and died the following day from bilateral pneumonia and multiple injuries. Concerns included the assessment of her suitability for a first-floor room, staffing levels and the absence of a manager, inconsistent risk and manual-handling assessments, and the strength and compliance of staircase furniture.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Regular absence of a manager at the home

    Wider context from the report

    “(2) Concerns were raised as to the staffing ratio to residents, and the lack of a manager at the home on that morning. The evidence indicated that as regards the latter point this was a regular occurrence. Please provide written evidence of current staffing requirements. ”

    Source location

    Marjorie Evelyne Keogh · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026